Keywords
multidisciplinary - perinatal - care conference - high risk - fetal
A significant number of pregnancies every year are considered high risk. These include,
but are not limited to complications such as hypertension, diabetes, multifetal gestation,
advanced maternal age and congenital fetal anomalies.[1]
[2] For instance, 6 to 8% of pregnant women in the United States have high blood pressure,
and between 2 and 10% suffer from gestational diabetes. Approximately 1 in every 880
U.S. births in 2014 was a triplet or higher order gestation.[3] As more couples choose to delay childbearing, the number of women aged 35 to 39
and 40 to 44 years has steadily increased across the United States since 1980, and
now account for 11.0 and 2.3 per 1,000 births, respectively.[4] Finally, approximately 1 in every 33 infants in the United States is born with a
birth defect, and account for 20% of all infant deaths.[5]
Maternal–fetal medicine (MFM) specialists often encounter these complex patients and
are tasked with coordinating their multidisciplinary (Multi-D) prenatal, intrapartum,
and neonatal care. This includes preconception care for women with medical or genetic
risk factors or prior adverse pregnancy outcomes, referral to specialists for various
obstetric, fetal, medical or surgical complications, intrapartum consultations resulting
from complications of labor or delivery, and referral to appropriate consultants for
ongoing management of complex issues in the postpartum state.[6] However, caring for the unborn fetus with anomalies is often even more challenging.
Numerous management questions, from ethical to surgical to logistical often plague
not only the treatment team but also the parents whose lives will be forever changed
by their interactions with the team.[7] A Multi-D approach involving MFM, neonatology, various pediatric surgical subspecialists,
cardiology, anesthesiology, palliative care, social work, case management, and various
institutional support staff members is often assembled to care for complex cases.
Multi-D team care is now routinely employed across the United States for certain birth
defects, such as cleft lip with or without cleft palate.[8] Although there is literature regarding the effectiveness of Multi-D team approaches
regarding outcomes, little is known about the attitudes and opinions of health care
providers toward the Multi-D care they provide. The purpose of this study was to assess
the attitudes and opinions of health care providers routinely involved in a Multi-D
team care model within a private practice setting at a high-volume community hospital.
Materials and Methods
In 2014, a monthly Multi-D perinatal care conference (PCC) was established at St.
David's Women's Center of Texas (large community hospital in Austin, TX) by the private
MFM and neonatology practitioners. The conference structure consists of (1) presentation
of new fetal anomaly cases by MFM providers from Austin MFM (first 20 minutes), (2)
presentation of complicated neonatal cases and follow-up of previously presented fetal
cases by neonatology (second 20 minutes), and (3) review of impending high-risk maternal
cases requiring Multi-D care by other specialties including anesthesiology, cardiology,
and social services (last 20 minutes). The invitations to attend were provided to
medical staff within the St. David's Healthcare system, as well as pediatric subspecialists
within the immediate market. Invitation to view the conference via the web was provided
to referring practices and facilities beyond the immediate Austin area.
To assess the effectiveness of the PCC, a survey, based on a revised version of the
Attitudes Toward Health Care Teams Scale, was created by adding two additional statements:
“The PCC is improving my medical knowledge” and “The PCC is achieving the goal of
creating a more complete approach to managing the care of our patients.”[9] The Attitudes Toward Health Care Teams Scale was created in an effort to measure
aspects of interprofessional collaboration, which is “a process that aims to provide
effective health services through teamwork among professionals from different backgrounds.”[9] The instrument contains a total of 19 questions, 18 of which are statements, participants
are asked to respond with their opinion based on a five-point Likert's scale.[10] The Likert's scale was created using 0 to represent “strongly disagree,” 1 representing
“disagree,” 2 representing “neutral,” 3 representing “agree,” and 4 representing “strongly
agree.” The survey was administered via a third-party service, SoGo Survey (www.sogosurvey.com, Herndon, VA). Participants who attend our institution's monthly PCC were invited
to complete the survey via e-mail and had the option of completing the survey anonymously.[10]
[11] The invitation was sent by our health system's continuing medical education department
to the invitee mail list outlined earlier. Due the anonymity of the assessment tool,
we were not aware of the details surrounding the respondents' attendance record. Results
from the responses were exported to an Excel document and reported as descriptive
data. The study was approved by our Institutional Review Board.
Results
The monthly PCC averaged 51 participants per meeting from inception in 2014 through
July 2015 when the survey assessment was sent to participants. Of the invitees, 42
(82.3%) responded to the survey. The participants included 11 physicians (26%), 15
nurses (35.7%), 14 sonographers (33.3%), and 2 individuals self-reported as other
in terms of job title (4.8%). In terms of age of respondents, 14.3% were between 21
and 30 years, 38.1% were between 30 and 40 years, and 47.6% were 40 years or older.
To avoid skewing the perception of the participants, the organizing MFM and neonatology
providers were excluded from the survey as they actively participated in the organization
and presentation of the conference on a regular basis.
A majority (64.3%) of respondents answered that they strongly agree with the statement
“Patients/clients receiving interprofessional care are more likely than others to
be treated as whole persons.” No respondents disagreed with that statement. When considering
statements regarding the time and resources required to plan interprofessional care
team processes, respondents' answers were more diverse, with 21.4% strongly disagreeing
with the statement, “Developing an interprofessional patient/client care plan is excessively
time consuming,” 47.6% disagreeing with the statement, 7.1% agreeing with the statement,
and another 7.1% strongly agreeing with the statement. However, most respondents (78.6%)
either disagreed or strongly disagreed that “In most instances, the time required
for interprofessional consultations could be better spent in other ways.” Respondents
also reported significant job satisfaction in interprofessional approaches, as 88.1%
of respondents either agreed or strongly agreed that “Working in an interprofessional
environment keeps most health professionals enthusiastic and interested in their jobs.”
Respondents tended to agree that efficiency of care was improved with interprofessional
approaches—92.2% of respondents either agreed or strongly agreed that “the interprofessional
approach makes the delivery of care more efficient.” In addition, all respondents
either agreed or strongly agreed that interprofessional care helps decrease medical
errors, with 66.7% of respondents strongly agreeing and 33.3% of respondents agreeing
with the statement, “Developing a patient/client care plan with other team members
avoids errors in delivering care.” Respondents also largely felt that interprofessional
care was not overly complex in nature, with 90.2% of respondents either disagreeing
or strongly disagreeing with the statement, “Working in an interprofessional manner
unnecessarily complicates things most of the time.”
When considering the impact of interprofessional care plans on the emotional and financial
needs of patients, 52.4% of respondents agreed and 33.3% of respondents strongly agreed
that “Health professionals working as teams are more responsive than others to the
emotional and financial needs of patients/clients.” Likewise, respondents largely
agreed that interprofessional care plans transcend patient care to also address the
needs of family members and caregivers—50.0% of respondents agreed and 38.1% of respondents
strongly agreed with the statement, “The interprofessional approach permits health
professionals to meet the needs of family caregivers as well as patients.”
Multi-D care also enhanced respondents' understanding of other health care professionals'
roles within the care team. Thirty-one percent of respondents agreed and 64.3% of
respondents strongly agreed with the statement, “Having to report observations to
a team helps team members better understand the work of other health professionals.”
When considering the transition from hospital care to home following discharge, 31.0%
of respondents agreed with and 50.0% of respondents strongly agreed that, “Hospital
patients who receive interprofessional team care are better prepared for discharge
than other patients.”
Respondents had similar views with regard to communication within interprofessional
care teams, with 31.0% of respondents agreeing and 64.3% of respondents strongly agreeing
that “Team meetings foster communication among team members from different professions
or disciplines.” The last two questions were added to the instrument to assess respondents'
opinions related to the PCC specifically. The majority of respondents believed that
the conference achieved its primary goal, as evidenced by 88.0% of respondents either
agreeing or strongly agreeing with the statement, “The PCC is achieving the goal of
creating a more complete approach to managing the care of our patients.” Finally,
respondent answers suggested that the vast majority consider interprofessional team
approaches to be associated with aggregate increases in medical knowledge, with 33.3%
of respondents agreeing and 64.3% of respondents strongly agreeing with the statement,
“The PCC is improving my medical knowledge.”
Discussion
Our survey of providers who regularly attend our monthly PCCs revealed many positive
attitudes and opinions toward interprofessional care of the maternal–fetal dyad. Providers'
responses suggested that the time spent involved in interdisciplinary team care improved
their job satisfaction as well as their medical knowledge, and resulted (in their
opinion) in meaningful outcomes with fewer medical errors and more complete care of
the patient. In addition, providers responded that interprofessional care approaches
transcended basic medical care by also addressing the social, financial, and emotional
needs not only of their patients but of their families and caretakers as well.
Improvements in technology, genetic screening, and access to medical care has facilitated
improved diagnosis and—in some cases—treatment of fetal anomalies, resulting in increasingly
complex care of the fetal patient. Initially adopted from the concept of tumor board
for cancer care, the perinatal conference, sometimes referred to as “fetal board,”
is the Multi-D approach to the abnormal fetal patient or complex mother.[12]
[13] Studies have demonstrated several improved outcomes as a result of a Multi-D approach
to complex maternal–fetal care, including changes in diagnosis, antenatal and postnatal
management, timing of delivery, improvement in emotional, social and financial family
well-being, and implementation of protocols that improve long-term outcomes.[12]
[13]
[14]
[15]
[16]
[17]
In 2011, the American College of Obstetricians and Gynecologists recommended that
the organization and governance of centers involved in fetal intervention should involve
a Multi-D team of health care providers.[18] For several reasons, MFM specialists are well suited to coordinate Multi-D care
of the complex maternal–fetal dyad: they are often the first member of the team to
interact with the patient and therefore possess a unique opportunity to establish
rapport and trust with the family,[8] and, by nature of their subspecialty training and knowledge of abnormal maternal
and neonatal physiology may refine the fetal diagnosis, alter the antepartum management
or guide the intrapartum process with the help of additional subspecialty providers.
There are little data regarding the prevalence of formalized Multi-D team care approaches
across the United States. A recent survey of 29 U.S. fetal care centers demonstrated
that the majority are administered by MFM specialists.[19] Although there are undoubtedly more medical centers across the country that likely
employ regular Multi-D team care processes, the current lack of a standardized assessment
tool makes ascertainment of these processes difficult. With this knowledge gap in
mind, we have shown that health care providers involved in a monthly PCC believe Multi-D
care approaches to be effective, pragmatic, and may result in improved patient, family,
and provider satisfaction. Although compelling for the implementation of a Multi-D
care approach to complex maternal–fetal patients, our results should be taken in the
context of our single-site institution, relatively small sample size, and lack of
preimplementation assessment. Future research should include an assessment of the
effectiveness of a Multi-D team approach from a patient and patient-family perspective.
The creation of a standardized tool for assessing the effectiveness of a Multi-D team
approach will hopefully assess the true goal of optimal and complete patient care.
